Successful lung transplantation for adolescents at a hospital for adults

To the Editor: I read with interest the article by Morton et al, summarising their impressive results of lung transplantation in adolescents treated in an adult hospital.1 The authors state they “do not have an exclusion policy for patients suitable for LTx [lung transplantation] based on age or size criteria alone”, and refer small or very young children to overseas units. The accompanying editorial by Snell et al comments that a paediatric transplant unit would have too low a caseload (four to eight transplants per year) to ensure they deliver good results.2 I agree that large-volume units are desirable, yet of the 158 centres reporting adult lung transplantation to the International Society for Heart and Lung Transplantation, 59% averaged fewer than 10 lung transplants a year.3

While a Surgical Fellow at St Louis Children’s Hospital, Mo, USA (1996–97), I was part of the surgical team undertaking a transplantation operation on a 13-month-old ventilator-dependent infant referred from Sydney. He had an uncomplicated postoperative course, leading to early hospital discharge and early return to Australia. Over the ensuing 5 years, while I was in touch with the family, they travelled regularly to St Louis for follow-up, as local expertise in managing young lung transplant recipients was lacking. Referring families to overseas units may be a good, albeit extremely expensive, short-term solution, yet developing local expertise in the follow-up of these patients has to be part of this package, to ensure optimal management, referrals and dialogue with overseas transplantation centres.

Such local expertise could provide the backbone of a future paediatric lung transplantation unit, preventing unnecessary deaths in this population. Although paediatric lung transplantation is challenging, results for isolated operations in children are similar to those in older age groups,3 so the “perception that the risk of undertaking LTx in children and adolescents does not warrant the reward”2 needs to be challenged. From 1990 to 2002, 190 children received transplants at St Louis Children’s Hospital (45% of them younger than 10 years), 30 of whom underwent living-related lung transplantation (generally reserved for patients too ill to wait for cadaveric lung transplants); although they were a higher-risk group, their survival statistics exceeded those of adult lung transplant patients.4

After all, a low case workload does not stop any of the four paediatric cardiac surgery units in this country from offering arterial switch operations. A local paediatric lung transplant follow-up service, perhaps attached to an adult unit, would be instrumental in optimising paediatric lung transplantation outcomes and could inform the debate on the pros and cons of setting up local paediatric lung transplantation services.